The Curious Case of the Deaths That Weren’t Due to COVID-19

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Last week, India’s Union health ministry published two press releases about COVID-19 that raised many eyebrows. The first was about the death of a 76-year-old man who later tested positive for COVID-19. He had recently visited Saudi Arabia, fell ill upon return and eventually succumbed. However, the press release used strange phrasing to announce this. It said the man was “confirmed to have died due to a co-morbidity”. When a person has more than one illness at the same time, they’re called comorbidities. The man had a history of asthma and hypertension.

Another press release issued the next day, about the death of a 68-year-old woman from Delhi who had COVID-19, repeated the language. She had likely contracted the virus from her son, and suffered from diabetes and hypertension. Again, the press release claimed her death was “confirmed to be due to a co-morbidity”.

Both statements imply that the two people – the first two Indians to succumb to COVID-19 – died not because of the novel coronavirus that is driving a global pandemic but because of the other illnesses they already had. In a press conference on March 13, the health ministry’s joint health secretary Lav Agarwal drove this point home, telling reporters they should “appreciate” that the two who had died had comorbidities. He was clearly implying that deaths such as theirs were rare in the ongoing epidemics, and not the norm.

This language is problematic for multiple reasons. First, all other facts in the press releases suggested the deaths were due to COVID-19, with the co-morbidities merely making the disease more severe. Both patients had displayed symptoms of COVID-19 within 14 days of possible exposure to the virus, and 14 days is the maximum incubation period of SARS-CoV-2 (the causative virus).

The man had developed fever and cough, both common initial symptoms of COVID-19, after returning from Saudi Arabia, a country with documented local transmission of the disease. When he visited a hospital, he was diagnosed with viral pneumonia, again a symptom of COVID-19.

The woman’s case had followed a similar trajectory. Both she and her son had fallen ill with fever and cough within 14 days of the son returning from Switzerland, also a country with local transmission. She eventually developed pneumonia; the press release said she also suffered from respiratory fluctuations and required a mechanical ventilator.

Based on the symptoms in the press release alone, Anupam Singh, an assistant professor of medicine at Ghaziabad’s Santhosh Medical College, said both patients likely succumbed to COVID-19.

The illnesses they already had – asthma, diabetes and hypertension – could well have contributed to the death. Data from a study from Wuhan shows that nearly 50% of patients who needed hospitalisation had underlying illnesses like hypertension, diabetes and coronary heart disease. The same study also found that older patients were more likely to succumb. However, just because diabetes made a person more vulnerable to COVID-19 doesn’t mean it killed them.

“A co-morbidity can contribute to death. But these comorbidities, which may worsen the severity of the infectious disease, can never be the direct cause of death,” Merlin Moni, an internal medicine specialist at Amrita Institute of Medical Sciences, Kochi, told The Wire Science.

Why then did the health ministry choose such misleading terminology? Several doctors I spoke to said this language might have been driven by political considerations, and a need to signal that the ministry had the outbreak under control. The government may have been trying to avoid panic by deliberately playing down the link between COVID-19 and death, said Parvaiz A Koul, who researches pulmonary medicine at Srinagar’s Sher-e-Kashmir Institute of Medical Sciences.

However, the bigger problem with downplaying COVID-19 deaths with comorbidities is that the latter are a defining feature of such outbreaks. Comorbidities determine who will develop a severe version of the illness and who won’t — much like climate change exacerbates existing climatic conditions in different ways. And this is the case not just with COVID-19; multiple infectious diseases, like severe acute respiratory syndrome (SARS), influenza, Middle Eastern respiratory syndrome (MERS) and dengue, behave this way. One of the reasons Italy – among the worst-hit countries today – registered such a large death toll from COVID-19 is because a fourth of its population, around 13 million people, is elderly and likely harboured comorbidities like cancer and diabetes.

Against this background, India ought to be more worried – not less – because the number of elderly people in India is higher than in Italy. According to the 2011 census, 5.3% of the Indian population is older than 65 years – roughly 64 million people. Meanwhile, India already has 49% of the world’s diabetes burden, a total of 72 million people. Even if 1% of this population was infected, they would likely develop a severe form of illness requiring ICU care and mechanical ventilation, said Giridhar R. Babu, an epidemiologist at the Public Health Foundation of India, New Delhi. And India simply doesn’t have as many ICU beds, mechanical ventilators or trained healthcare professionals to treat them.

Advanced age and chronic illnesses render people more vulnerable to infectious diseases in a number of ways. A 2010 study in macaques found that older animals infected with the SARS coronavirus – a close relative of SARS-CoV-2 – responded with a stronger immune response. This overreaction caused their bodies to produce high levels of proteins called cytokines, which can ravage the lungs. Earlier this month, a comment published in The Lancet hypothesised that a class of drugs used to treat patients with diabetes and hypertension could prompt human cells to produce higher quantities of ACE-2, a protein used by the SARS-CoV-2 virus to infect these cells. This way, the authors wrote, diabetic and hypertensive patients could be more vulnerable to COVID-19.

Morbid wordplay

The health ministry’s wordplay was thankfully restricted to the press releases. Another page on the ministry’s website lists the two deaths as COVID-19 deaths, doing away with any confusion the press release may have created.

Historically, however, Indian government agencies have often deployed syntactic tricks to hide the true scale of infectious diseases. An investigation by Al Jazeera in 2016 described the case of a 25-year old woman from Odisha who had died after her doctors diagnosed her with malaria. However, the death certificate listed the cause of death as cardiorespiratory failure – an example of a larger scheme the state had hatched to suppress malaria cases.

Singh, of Santhosh Medical College, said that during dengue epidemics in New Delhi, doctors in government hospitals would sometimes write “multi organ failure” as the cause of death on medical certificates in an attempt to hide dengue deaths. Babu also recalled instances of dengue being recorded as “pyrexia (fever) of unknown origin”. Such economy with the truth has contributed to official dengue numbers being lower than actual cases by a stunning factor of 282, according to an estimate published in the American Journal of Tropical Medicine and Hygiene.

The health ministry’s COVID-19 press releases, along with the malaria and dengue misreporting, are all textbook examples of how not to record causes of death. In normal circumstances, causes of deaths as certified by doctors are valuable indicators of the state of a nation’s health. It’s critical that they are recorded carefully.

This is why CDC guidelines require respiratory failure and multiple organ failure – both of which denote mechanisms by which the death occurred, not the etiology – never be listed as the cause of death on medical certificates. “The cause of death means the disease, abnormality, injury or poisoning that caused the death, not the mechanism of death, such as cardiac or respiratory arrest, shock or heart failure,” the guidelines read. This means the physician certifying the death would have to specify what led to multi-organ failure in the first place – whether an infection from a virus such as dengue or herpes simplex, or an injury in a traffic accident.

Can comorbidities kill?

All said, the scenario described in the health ministry’s press releases is also not impossible. Hypothetically, a diabetic person who contracts COVID-19 could also experience an aggravation of diabetes with no link to COVID19, and could die – meaning the diabetes caused the death. However, in such patients, the symptoms would look very different, according to Koul.

Diabetes doesn’t kill through pneumonia or respiratory failure but through complications like ketoacidosis, in which the blood is filled with acids called ketones. Kidney failure is yet another way. But there is no record of these symptoms in the press release, which leaves COVID-19. One way to establish the cause of death would be to conduct an autopsy, Koul said.

However, Raman Gangakhedkar, who leads the epidemiology division at the Indian Council of Medical Research, said no autopsy had been performed on the 76-year-old man. The director of the Gulbarga Institute of Medical Sciences, where he had been pronounced dead, and the director of New Delhi’s Ram Manohar Lohia hospital, where the 68-year-old woman had been treated, refused to answer any questions about causes of death.

Asked why the ministry’s first press release said the death was due to comorbidities, Gangakhedkar said that for any patient admitted for less than 24 hours, pinpointing the cause of death would be difficult. “I would accept any statement about the death with caution,” he said. But this doesn’t explain why the press release eschewed all caution and claimed unambiguously that the deaths were due to comorbidities.

Second, both press releases suggest that the patients experienced respiratory failure, a condition in which there isn’t enough oxygen in the blood. The first press release used the term “respiratory failure” as-is while the second said the patient had to be ventilated. Having to be ventilated implies the patient was unable to maintain enough oxygen in her blood, which in turn implies respiratory failure, Singh said. Gangakhedkar admitted that a combination of these symptoms – respiratory failure plus a positive lab test for COVID-19 – would imply that the cause of death was COVID-19.

Babu said such prevarication is possible because India has thus far recorded only 114 patients and two deaths from COVID-19. One reason for these small numbers is that India hasn’t commenced testing patients widely yet, limiting itself only to passengers from affected countries who also show characteristic symptoms, and their contacts. Such restricted testing can miss the true burden of infection because many travellers may have entered India even before the country began airport screening.

And once the number of COVID-19 cases rises, the number of people with both comorbidities and COVID-19 will start to surge. When that happens, it will be hard to say that the deaths are due to comorbidities alone, Babu said. Why, after all, would so many people with comorbidities die at the same time?

“Playing with terminology is a disease which India has. When the disease burden is low, it is possible to say this. Once there is an outbreak, it will stop… You can’t fool the virus for a long time.”